Spark Appointment and Invoice Form

A form for use by therapists who attend various types of appointment sand at different rates. The form allows reporting of appointments, and costing said appointments for application to an invoice. Create a HIPAA Compliant Spark Appointment and Invoice Form today.

Spark Appointment and Invoice Form

Instructions:This form is to be submitted to Spark Administration by 5 pm the Sunday prior to the next payday. Weekly submisssions would be preferred; however, bi-monthly are acceptable.Please review the dates, time activities listed and charges to ensure accruacy before submission.Do not forget to enter the client for each service - therapy, kilometers, meetings etc. for the same appointment. Use as many spaces as necessary.All km are to be entered as a full number. More than 0.5 the next higher full number will be inserted (4.6 = 5). If less than 0.5 the next lower whole number will be inserted (4.3 = 4).

Conversion Chart - Minutes to Digital

To be completed by Submitting RSW / TA

Full Name
*

First Name Last Name

E-mail of Therapist
*

If there is not enough space on this form for all the appointments submit this form and start a second one. Indicate how many submissions are being sent. Then assign a common number so the submissions can be linked. As an example: 3 submissions, numbered T1, T2, and T3.

How Many Submissions

Assign a Number

Invoice Start Date

-
Month
-
Day Year

Invoice End Date

-
Month
-
Day Year

Report Details

Client Initials1

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 1

Measure

Length of Service 1

Pay Rate 1

Special Pay 1 - Insert

Cost of Therapy - 1

Calculation 1a

Calculation 1b

Calculation 1c

Calculation Total - 1

Client Initials 2

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 2

Measure

Length of Service 2

Pay Rate 2

Special Pay 2 - Insert

Cost of Therapy- 2

Calculation 2a

Calculation 2b

Calculation 2c

Calculation Total - 2

Client Initials 3

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 3

Measure

Length of Service 3

Pay Rate 3

Special Pay 3 - Insert

Cost of Therapy- 3

Calculation 3a

Calculation 3b

Calculation 3c

Calculation Total - 3

Client Initials 4

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 4

Measure

Length of Service 4

Pay Rate 4

Special Pay 4 - Insert

Cost of Therapy- 4

Calculation 4a

Calculation 4b

Calculation 4c

Calculation Total - 4

Client Initials 5

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 5

Measure

Length of Service 5

Pay Rate 5

Special Pay 5 - Insert

Cost of Therapy- 5

Calculation 5a

Calculation 5b

Calculation 5c

Calculation Total - 5

Client Initials 6

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 6

Measure

Length of Service 6

Pay Rate 6

Special Pay 6 - Insert

Cost of Therapy- 6

Calculation 6a

Calculation 6b

Calculation 6c

Calculation Total - 6

Client Initials 7

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 7

Measure

Length of Service 7

Pay Rate 7

Special Pay 7- Insert

Cost of Therapy- 7

Calculation 7a

Calculation 7b

Calculation 7c

Calculation Total - 7

Client Initials 8

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 8

Measure

Length of Service 8

Pay Rate 8

Special Pay 8- Insert

Cost of Therapy- 8

Calculation 8a

Calculation 8b

Calculation 8c

Calculation Total - 8

Client Initials 9

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 9

Measure

Length of Service 9

Pay Rate 9

Special Pay 9- Insert

Cost of Therapy- 9

Calculation 9a

Calculation 9b

Calculation 9c

Calculation Total - 9

Client Initials 10

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 10

Measure

Length of Service 10

Pay Rate 10

Special Pay 10- Insert

Cost of Therapy- 10

Calculation 10a

Calculation 10b

Calculation 10c

Calculation Total - 10

Client Initials 11

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 11

Measure

Length of Service 11

Pay Rate 11

Special Pay 11- Insert

Cost of Therapy- 11

Calculation 11a

Calculation 11b

Calculation 11c

Calculation Total - 11

Client Initials 12

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 12

Measure

Length of Service 12

Pay Rate 12

Special Pay 12- Insert

Cost of Therapy- 12

Calculation 12a

Calculation 12b

Calculation 12c

Calculation Total - 12

Client Initials 13

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 13

Measure

Length of Service 13

Pay Rate 13

Special Pay 13- Insert

Cost of Therapy- 13

Calculation 13a

Calculation 13b

Calculation 13c

Calculation Total 13

Client Initials 14

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 14

Measure

Length of Service 14

Pay Rate 14

Special Pay 14- Insert

Cost of Therapy- 14

Calculation 14a

Calculation 14b

Calculation 14c

Calculation Total - 14

Client Initials 15

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 15

Measure

Length of Service 15

Pay Rate 15

Special Pay 15- Insert

Cost of Therapy- 15

Calculation 15a

Calculation 15b

Calculation 15c

Calculation Total - 15

Client Initials 16

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 16

Measure

Length of Service 16

Pay Rate 16

Special Pay 16- Insert

Cost of Therapy 16

Calculation 16a

Calculation 16b

Calculation 16b

Calculation Total - 16

Client Initials 17

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 17

Measure

Length of Service 17

Pay Rate 17

Special Pay17 - Insert

Cost of Therapy- 17

Calculation 17a

Calculation 17b

Calculation 17c

Calculation Total - 17

Client Initials 18

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 18

Measure

Length of Service 18

Pay Rate 18

Special Pay18- Insert

Cost of Therapy- 18

Calculation 18a

Calculation 18b

Calculation 18c

Calculation Total - 18

Client Initials 19

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 19

Measure

Length of Service 19

Pay Rate 19

Special Pay19- Insert

Cost of Therapy- 19

Calculation 19a

Calculation 19b

Calculation 19c

Calculation Total - 19

Client Initials 20

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 20

Measure

Length of Service 20

Pay Rate 20

Special Pay 20 - Insert

Cost of Therapy- 20

Calculation 20a

Calculation 20b

Calculation 20c

Calculation Total - 20

Client Initials 21

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 21

Measure

Length of Service 21

Pay Rate 21

Special Pay 21 - Insert

Cost of Therapy- 21

Calculation 21a

Calculation 21b

Calculation 21c

Calculation Total - 21

Client Initials 22

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 22

Measure

Length of Service 22

Pay Rate 22

Special Pay 22 - Insert

Cost of Therapy- 22

Calculation 22a

Calculation 22b

Calculation 22c

Calculation Total 22

Client Initials 23

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 23

Measure

Length of Service 23

Pay Rate 23

Special Pay 23 - Insert

Cost of Therapy 23

Calculation 23a

Calculation 23b

Calculation 23c

Calculation Total - 23

Client Initials 24

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 24

Measure

Length of Service 24

Pay Rate 24

Special Pay 24 - Insert

Cost of Therapy- 24

Calculation 24a

Calculation 24b

Calculation 24c

Calculation Total - 24

Client Initials 25

Appointment Date

-
Month
-
Day Year

Time of Service

Type of Service 25

Measure

Length of Service 25

Pay Rate 25

Special Pay 25 - Insert

Cost of Therapy- 25

Calculation 25a

Calculation 25b

Calculation 25c

Calculation Total 25

Enter the total of all tax (HST) that you are charging Spark for the services listed in this invoice. Enter 0 if there are no tax charges.